Provider Demographics
NPI:1851419758
Name:BYRUM, NICOLE (MMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BYRUM
Suffix:
Gender:F
Credentials:MMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TIMBER TRAIL DR
Mailing Address - Street 2:APT. 308
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4666
Mailing Address - Country:US
Mailing Address - Phone:325-280-7142
Mailing Address - Fax:
Practice Address - Street 1:100 SAW MILL RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5592
Practice Address - Country:US
Practice Address - Phone:765-742-4848
Practice Address - Fax:765-477-9905
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100445230AMedicaid